Subretinal fibrosis after photodynamic therapy in subfoveal choroidal neovascularisation in highly myopic eyes

3-Methyladenine Alleviates Experimental Subretinal Fibrosis by Inhibiting Macrophages and M2 Polarization Through the PI3K/Akt Pathway

Purpose: To explore the effects of 3-methyladenine (3-MA), a selective inhibitor of phosphatidylinositol-3-kinase (PI3K), on experimental subretinal fibrosis (SRF) in mice. Methods: The SRF mouse model was established by 532 nm laser photocoagulation at each fundus of mice on day 0. 3-MA was administered every 2 days from day 0 to 35. Immunofluorescence of choroidal flat mounts was performed to evaluate the size of SRF area, local macrophages, and polarization, respectively. Besides, Western blot analysis was carried out to assess the expression levels of macrophage polarization-related genes, Arg-1, Ym-1, and transforming growth factor-β₂ (TGF-β₂). Co-culture and migration experiments were used to demonstrate the inhibitory effect of 3-MA on fibroblasts. The gene knockout and Western blot analysis were used to explore the signal pathways related to macrophage polarization. Results: Compared with the control group, the 3-MA-treated group showed significantly less size of SRF area. 3-MA treatment reduced both circulating and local macrophages, and counteracted M2 polarization. Moreover, 3-MA inhibited fibroblast recruitment. Mechanistically, we proved that 3-MA inhibits macrophage M2 polarization by suppressing PI3K/Akt signal pathway rather than the PI3K-autophagy-related signal pathway. Conclusions: 3-MA exerts antifibrotic effects on experimental SRF by targeting circulating and local macrophages and M2 polarization, through PI3K/Akt signal pathway. These results support the potential use of 3-MA as a new therapeutic modality for SRF associated with neovascular age-related macular degeneration.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES OF SUBRETINAL FIBROSIS AFTER MYOPIC NEOVASCULARIZATION

PURPOSE

To describe the optical coherence tomography (OCT) angiography features of subretinal fibrosis in eyes with myopic choroidal neovascularization after natural evolution or secondary to intravitreal anti-vascular endothelial growth factor therapy.

METHODS

Retrospective observational case series. All eyes underwent a multimodal imaging examination including fluorescein angiography, spectral domain OCT, OCT angiography, and en face OCT.

RESULTS

Twenty-five eyes of 25 patients with mean age of 56.4 ± 14.9 were included in the study. Subretinal fibrosis was diagnosed at mean 30 (range 6-116) months before inclusion. Within the subretinal fibrosis, an abnormal vascular network was observed in 20/25 (80%) eyes, located typically in the outer retina (18/20, 90%) or the choriocapillaris (14/20, 70%) segmentation. The most prevalent patterns were "round tangle" and "tapered tangle." On en face OCT, the subretinal fibrosis was evidenced in 24/25 (96%) eyes, most prevalently in the outer retina (21/25, 84%) and in the choriocapillaris (18/25, 72%), where main feature was white-hyperreflective (20/21, 95%) and dark-hyporeflective (17/18, 94%) appearance, respectively. The presence of subretinal fibrosis on en face OCT was positively correlated with the presence of abnormal vascular network on OCT angiography in 61% of the cases (P = 0.005).

CONCLUSION

Subretinal fibrosis secondary to myopic choroidal neovascularization frequently contains blood flow within a persistent abnormal vascular network as assessed by OCT angiography.

One-Year Results of Fixed Aflibercept Treatment Regime in Type 3 Neovascularization

PURPOSE

To evaluate the effect of intravitreal aflibercept injections in treatment-naive type 3 neovascularization using a fixed treatment regime during the first year of therapy.

METHODS

Fourteen eyes of 14 patients diagnosed with type 3 neovascularization were studied. All patients were treated with intravitreal aflibercept injections using a fixed treatment regime of 3 consecutive monthly dosages followed by 2-month interval injections. Results were assessed after a 12-month follow-up period. Changes of best corrected visual acuity (BCVA), central retinal thickness (CRT), central macular volume (CMV), and retinal pigment epithelium (RPE) atrophy at fundus autofluorescence and infrared reflectance images were recorded and analyzed.

RESULTS

BCVA improved from 60.3 ± 11.7 ETDRS letters at the baseline to 70.9 ± 10.3 ETDRS letters at 12-months follow-up (p = 0.036). Also, CRT and CMV statistically improved after the treatment (from 425 ± 117 to 308 ± 117 µm [p = 0.031] and from 9.52 ± 1.90 to 8.29 ± 0.95 mm3 [p = 0.073], respectively). In 4 patients, development and progression of RPE atrophy were observed, and it was associated with the presence of serous pigment epithelium detachment at the baseline. Furthermore, the development of a fibrotic lesion eccentric to the fovea was observed in 5 patients, without significant impairment of BCVA (p = 0.290).

CONCLUSION

Intravitreal aflibercept administered in a fixed treatment regime during the first year of therapy may be effective for the improvement and stabilization of BCVA in eyes with type 3 neovascularization. However, RPE atrophy and subretinal/intraretinal fibrosis can develop during the treatment.

Clinical outcomes and predictors of response to photodynamic therapy in symptomatic circumscribed choroidal hemangioma: A retrospective case series

Background

To investigate the treatment outcomes and predictors of response to photodynamic therapy (PDT) in patients with symptomatic circumscribed hemangioma (CCH).

Methods

This retrospective case series examined 20 patients with symptomatic CCH (10 submacular CCHs and10 juxtapapillary CCHs) who underwent standard PDT (wavelength: 662 nm; light dose: 50J/cm²; exposure time: 83 sec) with verteporfin (6mg/m²), either as monotherapy (n = 9) or in association with other treatments (n = 11), of which 7 received intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF). A post-PDT improvement of at least two lines in best-corrected visual acuity (BCVA) was the primary outcome measure. Predictors of response were investigated with binary logistic regression analysis.

Results

Seventeen (85%) patients received one PDT session, and three patients (15%) underwent PDT at least twice. Ten patients (50%) achieved the primary outcome of a post-PDT BCVA improvement of at least two lines. Macular atrophy and recalcitrant cystoid macular edema in 2 patients. Binary logistic regression analysis revealed that younger age (< 50 years) (P = 0.033), pre-PDT BCVA of ≧20/200 (P = 0.013), exudative retinal detachment resolved within one month after PDT (P = 0.007), and a thinner post-PDT tumor thickness (P = 0.015) were associated with the achievement of a post-PDT BCVA improvement. Additional treatments to PDT including IVI anti-VEGF did not appear to improve visual and anatomical outcomes.

Conclusions

Symptomatic CCHs respond generally well to PDT. Patients with younger age (< 50 years), pretreatment BCVA≥ 20/200, and thinner foveal edema are most likely to benefit from this approach.

Sequential Combined Therapy for Treatment of Choroidal Neovascularization in Age-Related Macular Degeneration: Photodynamic Therapy and Thermal Laser Photocoagulation

PURPOSE

To analyze the results achieved after treating extrafoveal choroidal neovascularization (CNV) recurrences with thermal laser photocoagulation (TLP) in patients who had previously undergone photodynamic therapy (PDT).

PATIENTS AND METHODS

Seven eyes (seven patients: four women and three men) that had been initially treated by PDT for CNV associated with age-related macular degeneration (ARMD) and then developed extrafoveal recurrences were treated with green argon TLP. All patients underwent a complete ophthalmologic evaluation and fluorescein angiography. Mean age was 74.4 +/- 4.4 years (range, 69 to 81 years). Five right eyes and two left eyes were treated. Mean follow-up after the beginning of the treatment with PDT was 18.0 +/- 3.5 months (range, 11 to 22 months). Follow-up after TLP was 6.8 +/- 1.0 months (range, 6 to 8 months).

RESULTS

Mean best-corrected visual acuity (BCVA) before treatment was 20/150 (range 20/400 to 20/40). After PDT it was 20/281 (range, 20/400 to 20/80), with a mean of 3.1 +/- 0.8 treatments (range, 2 to 4). After TLP, BCVA was 20/233 (range, 20/400 to 20/80), with no statistically significant difference from BCVA after PDT (p = 0.06, Student's t-test paired data). In all cases total closure of CNV was achieved after only one session of TLP.

CONCLUSIONS

TLP could be helpful in association with multiple sessions of PDT in order to achieve a complete closure of subfoveal CNV secondary to ARMD. Further studies are required to confirm our findings.

SUBRETINAL FIBROSIS AFTER ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN EYES WITH MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To assess the incidence and risk factors of subretinal fibrosis and their impact on visual outcome in eyes with myopic CNV.

METHODS

Medical records of 72 eyes treated with antivascular endothelial growth factor (anti-VEGF) therapy in a pro re nata regimen for myopic CNV that followed up for more than 1 year were retrospectively reviewed. The presence of subretinal fibrosis after anti-VEGF therapy was determined using both fundus photographs and optical coherence tomography. The incidence and risk factors of subretinal fibrosis were evaluated, and best-corrected visual acuity was compared between the eyes with and without subretinal fibrosis.

RESULTS

The incidences of subretinal fibrosis during the 1-year and whole follow-up period were 31.9% and 36.1%, respectively. Occurrence of subretinal fibrosis was associated with frequent CNV recurrence (P = 0.005) and poor baseline best-corrected visual acuity (P = 0.044) in a Cox proportional hazard model. Anatomically, the eyes with subretinal fibrosis showed more frequent progression of chorioretinal atrophy (95.7% vs. 71.4%, P = 0.027) and less frequent photoreceptor recovery (17.4% vs. 65.3%, P < 0.001) after anti-VEGF therapy. Occurrence of subretinal fibrosis was associated with poor vision at baseline (P = 0.011) and the final visit (P = 0.008) when compared with the findings in the nonoccurrence group.

CONCLUSION

Development of subretinal fibrosis after anti-VEGF therapy was common in eyes with myopic CNV and was associated with CNV recurrence. Myopic eyes with subretinal fibrosis show progressive chorioretinal atrophy and poor visual outcome.

[Treatment of high myopic choroidal neovascularisation with intravitreal bevacizumab]

PURPOSE

To evaluate the safety and efficacy of intravitreal bevacizumab (IVB) in the treatment of high myopic choroidal neovascularization (CNV).

MATERIALS AND METHODS

Retrospective study of 16 eyes of 16 patients with high myopic choroidal neovascularization treated with first-line IVB (1.25mg/0.05mL) with a one-year follow-up. All patients underwent a complete baseline (M0) ophthalmologic examination, including the measurement of best corrected visual acuity (BCVA), biomicroscopic and fundus examination, fluorescein and indocyanine green angiography, and optical coherence tomography. Patients were followed monthly. Additional IVB was administered when persistent or additional retinal exudation was observed. The main study parameters were visual acuity at 1, 6 and 12 months and the progression of exudation on OCT and angiography.

RESULTS

Mean age was 63±14 years and spherical equivalent was -15.4±7.4 diopters. Baseline BCVA was 0.75±0.5 logMAR. Mean follow-up was 15±2 months. The average number of IVB was 2.4±1.2 injections. Metamorphopsia decreased in all patients and completely disappeared in fourteen eyes. Mean BCVA was 0.5±0.3 logMAR at M1 and 0.6±0.5 logMAR at M6 and M12. No adverse events related to the intravitreal injections were observed.

CONCLUSION

Our study showed that IVB (Avastin(®)) is effective in the treatment of high myopic CNV. Moreover, only a small number of intravitreal injections were required to treat this condition.

Choroidal neovascularization in pathological myopia

Myopic choroidal neovascularization (CNV) is one of the leading causes of visual impairment worldwide. The clinical and socioeconomic impact of myopic CNV in Asian countries is particularly significant due to rising trend in the prevalence and severity of pathological myopia. The exact pathogenesis of myopic CNV remains unclear and there is paucity of information with respect to incidence and risk factors for myopic CNV from prospective studies. Furthermore, there are no recognized measures that may prevent or delay the development of CNV in eyes with pathological myopia. Advances have been made in the diagnosis and characterization of myopic CNV over the years. Until recently, treatment modalities for myopic CNV were limited to thermal laser photocoagulation and photodynamic therapy with verteporfin, both these modalities primarily aim at prevention of further visual loss. In the last 5 years, inhibitors of vascular endothelial growth factor (VEGF) have been used successfully and may improve vision to some extent. Nevertheless, the long-term safety and efficacy of anti-VEGF agents remains unknown. Furthermore, the risk of developing chorioretinal atrophy remains the key factor in determining the final visual outcome. This review article summarizes the current literature on myopic CNV, highlighting new evolving diagnostic and treatment modalities, prognostic factors influencing visual outcome, and areas of future research.

Intravitreal bevacizumab to treat myopic choroidal neovascularization: 2-year outcome

BACKGROUND

Myopic maculopathy is the leading cause of subfoveal choroidal neovascularization (CNV) among patients under 50 years of age. New antiangiogenic drugs are being used off-label to treat myopic CNV and the short-term outcome of these therapies has been reported. The aim of this study is to report the changes in best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) in highly myopic CNV treated by intravitreal bevacizumab at 2 years.

METHODS

Prospective non-randomized, interventional case series study of 19 highly myopic eyes from 18 patients with subfoveal and juxtafoveal CNV treated by three monthly intravitreal injections of 1.25 mg bevacizumab. Patients were evaluated for BCVA and OCT at baseline and then monthly for 2 years.

RESULTS

Eleven eyes were naive for treatment and eight eyes had been previously treated by photodynamic therapy. LogMAR BCVA averaged 0.54 (SD 0.25, range 0.2-1.0; Snellen 20/69) at baseline; 0.40 (SD 0.35, range 0.0-1.2; Snellen 20/50) at 1 year; and 0.47 (SD 0.31, range 0.0-1.0; Snellen 20/59) at 2 years (p = 0.04 and p = 0.20, respectively, Student's t test paired data). Re-treatment was performed in four eyes during the first year: three eyes at month six and one eye at month 12. Four eyes required one re-injection during the second year at months 14, 18, 20, and 24. Neither ocular nor systemic adverse reactions were detected.

CONCLUSIONS

Intravitreal bevacizumab seems to be effective for subfoveal and juxtafoveal CNV in highly myopic eyes. BCVA gain decreases and is no longer significant by the end of the second year.

Two years follow-up outcome of verteporfin therapy for subfoveal choroidal neovascularization in pathologic myopia in Indian eyes

CONTEXT

In India, refractive errors are a major cause of treatable blindness. Population surveys in southern India have shown prevalence of high myopia to be 4.32-4.54%. Photodynamic therapy (PDT) for choroidal neovascularization (CNV) caused by pathologic myopia is beneficial.

AIMS

To report the 24 months outcome of PDT with verteporfin for subfoveal CNV caused by pathologic myopia in Indian eyes.

SETTINGS AND DESIGN

Prospective case series.

MATERIALS AND METHODS

Review of prospectively collected data of Indian patients with pathologic myopia and subfoveal CNV treated with verteporfin therapy between 2001 and 2005 using standard regimen for PDT.

STATISTICAL ANALYSIS USED

Wilcoxon signed rank test was used to see the difference in the mean letter acuity at intervals compared to baseline. Kaplan Meier Survival analysis was done to estimate the success rate of verteporfin therapy for CNV caused by pathologic myopia.

RESULTS

Fifteen patients (15 eyes) treated with standard fluence PDT and who had completed 24 months follow-up were analyzed. The mean spherical equivalent was -13.36 +/- 5.88 diopter. Five out of 15 eyes in six months, three out of 15 eyes at 12 months and four eyes out of 15 at 24 months had improved vision by > 10 letters. The mean number of treatment session was 2.2 in two years.

CONCLUSIONS

PDT with verteporfin for subfoveal CNV caused by pathologic myopia in Indian eyes is effective.

Retinal pigment epithelial marginal retraction after photodynamic therapy for choroidal neovascularization in pathologic myopia

PURPOSE

To report the incidence of retinal pigment epithelial (RPE) marginal retraction after verteporfin photodynamic therapy (PDT) for subfoveal choroidal neovascularization (CNV) in pathologic myopia (PM).

METHODS

Retrospective review of 236 patients treated with PDT for subfoveal CNV due to PM.

RESULTS

RPE marginal retraction was found in 3 eyes (1.3%), and a decrease of a mean of five lines of vision was reported to occur 10-15 days after treatment. At the end of followup two eyes lost three lines and one six lines from baseline.

CONCLUSIONS

RPE marginal retraction as an early complication of PDT for subfoveal CNV secondary to PM is rare. The low incidence of this adverse event, however, should not preclude recommendations for PDT in myopic eyes that could benefit from this treatment modality.

Combined photodynamic therapy and intravitreal triamcinolone injection for the treatment of choroidal neovascularisation secondary to pathological myopia: a pilot study

Intravitreous triamcinolone associated with PDT should preferably be used among elderly patients who usually show lower visual acuity and a poorer response to PDT, or among patients with recurrent or greater CNVs

Photodynamic Therapy Using Verteporfin for Choroidal Neovascularization Associated with Angioid Streaks – Long-Term Effects

AIM

To investigate the safety and efficacy of photodynamic therapy with verteporfin (PDT) in patients with choroidal neovascularization associated with angioid streaks (CNVAS).

METHODS

A nonrandomized, prospective clinical investigation of 12 patients with CNVAS was performed. PDT was based on the criteria concerning the treatment of age-related macular degeneration.

RESULTS

The mean follow-up was 41.75 months (range 24-60). The mean number of (re)treatments was 3.3 (range 2-7). Visual acuity improved by at least 1 line in 42%, was stable within +/-2 lines in 33%, decreased by at least 1 line in 58% and by >3 lines in 25% of the patients. The mean visual acuity was 0.30 (range 0.2-0.5) prior to and 0.17 (range 0.03-0.6) after the final PDT. The mean visual acuity of the contralateral eye was 0.1. 75% of contralateral eyes and 25% of the treated eyes had a final visual acuity of < or =0.1 (20/200). At the final follow-up, a significant enlargement of the lesion size was noted in 92% of the cases.

CONCLUSION

Using the current (re)treatment criteria, PDT does not appear to limit the growth of CNVAS. Compared to the aggressive natural course and to the limited treatment options, PDT may at least in part help to stabilize macular function over a limited period of time.

Choroidal neovascularisation in pathological myopia: an update in management

Choroidal neovascularisation (CNV) secondary to pathological myopia is an important cause of significant visual impairment in young and middle aged adults globally and is particularly prevalent in Asian populations. In the past few years, there have been rapid advancements in the different treatments for myopic CNV. The purpose of this perspective is to give an overview of the natural history of myopic CNV and the various treatment options including laser photocoagulation, photodynamic therapy, sub-macular surgery, and macular translocation surgery. Future directions in the management of myopic CNV are also discussed.

Detection of connective tissue growth factor in subretinal Fluid following retinal detachment: possible contribution to subretinal scar formation, preliminary results

Connective tissue growth factor (CTGF) has been shown to be substantially involved in various processes of fibrosis. Herein we report on the presence of CTGF in the subretinal fluid (SRF) of patients with retinal detachment.

METHODS

Samples of SRF were collected from 10 patients during retinal detachment surgery. Specific ELISA analysis was performed with goat IgG against human CTGF.

RESULTS

CTGF was above the detection limit of the assay in all samples. On average the concentration of CTGF in SRF was 10 ng/ml (SD 3.7, range 3.7-15.7 ng/ml). There was an increase in the CTGF concentration with time between the diagnosis of retinal detachment and surgery (correlation r = 0.67).

CONCLUSION

CTGF appears to be a constant component of the fluid accumulating in the subretinal space after retinal detachment. The origin of subretinal CTGF and its physiological importance is still unclear. The known effects of CTGF, however, suggest that it may be involved in both the physiological processes of wound healing in the subretinal space and also in the pathological events such as subretinal fibrosis. The observed increase in CTGF concentration with time suggest that CTGF plays a role in the pathophysiology of subretinal scarring in cases of delayed retinal surgery.

Late-onset visual decline following successful treatment of subfoveal choroidal neovascularisation with photodynamic therapy

Photodynamic therapy (PDT) has been shown in large studies to be capable of achieving closure of choroidal neovascularization (CNV), thereby resulting in stabilization of visual acuity. We report a series of four patients with classic CNV treated with PDT with good initial result but subsequent severe visual loss that may be related to a change in the morphology of the subretinal scar.

Quantitative assessment of the long-term effect of photodynamic therapy in patients with pathologic myopia

BACKGROUND

In patients with classic subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia (PM), photodynamic therapy (PDT) has been shown to stabilize the visual acuity. We have analyzed the long-term visual prognosis after PDT in patients with CNV secondary to PM.

METHODS

In a retrospective study we reviewed the clinical charts of 102 patients. PDT was performed following the procedures described in the VIP and TAP study protocols. Follow-up examinations and PDT treatment were scheduled in 3-month intervals. Indications for retreatment were an active leaking CNV in combination with visual disturbances or visual loss. To assess treatment effects we analyzed the number of letters read on the ETDRS charts. The primary efficacy outcome was the proportion of eyes that had fewer than eight letters loss or gain at 24 months. Secondary efficacy outcomes included the proportion of eyes that had fewer than 15 letters loss or gain and the proportion of eyes that had fewer than 30 letters loss or gain at month 24.

RESULTS

One hundred and two patients were included into the study. Mean follow-up was 32.5+/-5.7 months. Patients received an average of 2.2 treatments from study entry through the last follow-up, resulting in a total of 221 PDT sessions throughout the study. At 24 months 46% lost at least eight letters. A loss of at least 15 (30) letters was observed in 25% (8%). Improvement of at least eight letters was noted in 8%. Larger improvements of at least 15 letters occurred only in 4% of study eyes.

CONCLUSION

Our study suggests that PDT can increase the chance of stabilizing or improving vision compared with the placebo arm of VIP trial.

Myopic choroidal neovascularization: natural course and treatment

PURPOSE OF REVIEW

Choroidal neovascularization (CNV) is the most common vision-threatening complication of high myopia. Myopic CNV has recently attracted a lot of attention, mainly because of a variety of newly developed treatments. To evaluate the efficacy of these new treatments against myopic CNV, we need to know more precisely the natural course of myopic CNV. The results of most previously reported studies regarding the natural course of myopic CNV, however, are somewhat contradictory. In this review, we describe the recently reported long-term prognosis of myopic CNV and the effectiveness of newly developed treatments as well as an overview of possible future treatments.

RECENT FINDINGS

A recent study evaluating the visual outcome of myopic CNV for at least 10 years after onset in a large series of patients reported that the visual prognosis of myopic CNV without treatment is extremely poor, mainly because of the secondary development of chorioretinal atrophy around the area of regressed CNV. Although conventional treatments against myopic CNV, such as laser photocoagulation or surgical extraction of CNV, have not been effective, newly developed treatments such as foveal translocation or photodynamic therapy have had favorable results on myopic CNV in the short-term. Pharmacologic interventions to treat or prevent CNV are also expected in the future.

SUMMARY

Because the natural prognosis of myopic CNV is extremely poor, treatment to prevent further visual loss is necessary. Based on the steady and gradual visual decrease in myopic CNV over the long term, however, long-term results are needed before the true effectiveness of the newly developed active treatments can be determined.